Polyarthritis with chondronecrosis associated with osteonecrosis, panniculitis and pancreatitis

Fatal case of pancreatic panniculitis and polyarthritis due to pancreatic neuroendocrine tumor: a case report and review of literature

Pancreatic panniculitis (PP) and arthritis may be extrapancreatic manifestations of pancreatic disease. The triad of pancreatic disease, panniculitis and polyarthritis, described in the literature as the PPP syndrome, is sometimes observed in patients with acute or chronic pancreatitis, pancreatic cancer or neuroendocrine tumors (NETs). We present a 60-year-old man with polyarthritis and clinically aggressive PP of the limbs. Computed tomography showed a large tumor in the uncinate process of the pancreas and multiple metastatic lesions in the liver and lungs. The skin nodules developed before the diagnosis of the occult pancreatic tumor and metastases. Biopsy of the skin nodules was performed and showed lobular panniculitis. In addition, immunopathology of the liver metastasis showed NET, a rare pathological variant. The skin lesions immediately spread to the upper limbs with extensive ulceration and necrosis, accompanied by high serum lipase levels. The patient died 4 months after the initial development of the skin lesion. PPP syndrome is a rarely recognized clinical entity. The present case report and literature review highlight the key clinical features of PPP syndrome. The absence of general or abdominal symptoms and skin changes mimicking other forms of panniculitis may lead to delayed diagnosis. It is important to broaden the diagnostic work-up for pancreatic disease in patients presenting with panniculitis and arthritis.

Pancreatitis, Panniculitis, and Polyarthritis Syndrome in Two Patients: A Case Series and Literature Review

Pancreatitis, panniculitis, and polyarthritis (PPP) syndrome presents a unique challenge in diagnosis and management because of its rarity and heterogeneous initial presentation. This manuscript presents a case series of two patients with PPP syndrome, shedding light on the diagnostic process and care for this uncommon condition. PPP syndrome is characterized by the simultaneous occurrence of pancreatitis or pseudocysts alongside polyarthritis and panniculitis. While its exact pathophysiology remains obscure, pancreatic inflammation is assumed to trigger the hematogenous dissemination of pancreatic enzymes, leading to fat necrosis and subsequent panniculitis, as well as chondronecrosis and/or osteonecrosis causing polyarthritis. Despite its recognition in medical literature since the late 1980s, PPP syndrome remains poorly understood, with only a limited number of cases reported globally. Its rarity and varied initial manifestations often result in misdiagnosis, causing delays in appropriate treatment. The presented case series highlights key clinical features and diagnostic clues of PPP syndrome. Both patients exhibited initial symptoms of inflammatory polyarthritis, accompanied by characteristic findings of "ghost cells" on skin biopsy. Additionally, radiographic and laboratory evidence revealed pancreatic changes consistent with this syndrome. This case series underscores the importance of multidisciplinary collaboration in managing PPP syndrome. Early recognition and accurate diagnosis are pivotal in initiating prompt and effective therapeutic interventions, thereby improving patient outcomes and minimizing long-term sequelae.

Pancreatitis, panniculitis and polyarthritis (PPP) syndrome

A young male presented with intermittent high-grade fever, asymmetric polyarthritis and erythematous, tender nodules over left shin for 2 months duration. He had a history of alcohol dependence with multiple episodes of acute pancreatitis. With polyarthritis progressing relentlessly, unresponsive to non-steroidal anti-inflammatory drugs and steroids, a provisional diagnosis of sarcoidosis was considered. Indeed, he was treated with azathioprine and rituximab with no effect. Biopsy of the skin nodule revealed subcutaneous fat necrosis, foam cells, deposition of eosinophilic amorphous material and calcification. Synovial fluid aspiration from the arthritic knee obtained purulent but surprisingly culture-negative material, rich in triglycerides. Abdominal CT confirmed chronic pancreatitis. Final diagnosis of pancreatitis, panniculitis and polyarthritis (PPP) syndrome was made. He underwent surgical pancreatic ductal drainage leading to complete remission of symptoms. PPP syndrome triad occurs due to leakage of pancreatic enzymes into systemic circulation and subsequent fat necrosis. Surgical drainage of pancreatic duct is often curative.

Pancreatitis, Panniculitis, and Polyarthritis Syndrome Detected on 99mTc-MDP Bone Scan

ABSTRACT

Pancreatitis, panniculitis, and polyarthritis syndrome is a rare disease. A 49-year-old man recently complained of bilateral ankle and epigastric pain. An ankle x-ray showed subcutaneous soft tissue swelling. Subsequent 99mTc-MDP bone scan showed foci of abnormal activity around joints in all extremities, especially in the knees and ankles. In addition, multiple nodular calcifications in the head of the pancreas were found in the abdominal CT scan. The patient also had increased blood amylase and lipase. The symptoms were resolved after the treatment of his pancreatitis.

Pancreatitis, panniculitis, and polyarthritis syndrome complicated with terminal pancreatic adenocarcinoma managed with intra-articular knee aspiration, intra-articular lidocaine and corticosteroid injection, and decompression of panniculitis: A case report

Pancreatitis, panniculitis, and polyarthritis (PPP) syndrome is a rare triad of hyperlipasemia, erythematous cutaneous nodules, and oligo- or mono-arthritis and a rare complication of pancreatic diseases. The treatment for PPP syndrome complicated by untreatable pancreatic diseases can be challenging because the causal treatment may not be available. Herein, I report a case of a 72-year-old man presenting with PPP syndrome, complicated by untreatable terminal pancreatic adenocarcinoma, who was successfully managed with intra-articular knee aspiration, intra-articular injection of lidocaine and corticosteroid, and decompression of panniculitis.

Clinical characteristics, treatment, and outcome of pancreatitis, panniculitis, and polyarthritis syndrome: a case-based review

A 42-year-old Caucasian female presented with lower limb panniculitis and bilateral ankle arthritis in the absence of abdominal or other localizing symptoms. Abdominal imaging revealed subacute pancreatitis with pseudocyst formation. The clinical manifestations were compatible with pancreatitis, panniculitis, and polyarthritis syndrome (PPP syndrome), a very rare complication of pancreatic disease. The patient improved with conservative treatment for the pancreatic disease and systemic corticosteroids for the cutaneous and articular manifestations. We identified 59 patients with the PPP syndrome from the literature, the majority of patients being male (74.6%) with a median age of 49 (IQR 41-63.5) years. Acute pancreatitis is the most frequent underlying disorder (54.2%), but gastrointestinal symptoms are absent in 45.8% of patients. Pancreatic panniculitis has a predilection for the lower limbs, which are affected in 98.3% of cases. However, the cutaneous lesions may also involve the upper limbs and trunk. Arthritis is typically symmetric and polyarticular in nature, affecting both large and small joints. Of all patients who received treatment, 78.6% had a poor response. Death occurred in 27.1% of cases after a median duration of 8 (IQR 3.5-14) weeks.

A rare case of a patient with PPP syndrome presenting pancreatic pseudocysts, panniculitis, and symptoms of polyarthritis. A radicular cyst of the upper jaw could be another manifestation of the syndrome

In rare cases, pancreatic enzymes can enter the bloodstream and cause fat necrosis in the bone and tissue leading to a disorder called pancreatitis, panniculitis, and polyarthritis syndrome. Clinicians should have this syndrome in mind when treating patients with pancreatitis.

Pancreatitis, panniculitis and polyarthritis (PPP-) syndrome caused by post-pancreatitis pseudocyst with mesenteric fistula. Diagnosis and successful surgical treatment. Case report and review of literature

INTRODUCTION

Pancreatitis, panniculitis and polyarthritis syndrome is a very rare extra-pancreatic complication of pancreatic diseases.

PRESENTATION OF CASE

While in most cases this syndrome is caused by acute or chronic pancreatitis, we report a case of a 62-year-old man presenting with extensive intraosseous fat necrosis, polyarthritis and panniculitis caused by a post-pancreatitis pseudocyst with a fistula to the superior mesenteric vein and extremely high blood levels of lipase. This became symptomatic 2.5 years after an episode of acute pancreatitis and as in most cases abdominal symptoms were absent. Treatment by surgical resection of the pancreatic head with the pseudocyst and mesenteric fistula led to complete remission of all symptoms.

DISCUSSION

A review of the literature revealed that all publications are limited to case reports. Most authors hypothesize that an unspecific damage can cause a secretion of pancreatic enzymes to the bloodstream leading to a systemic lipolysis and fat tissue necrosis, especially of subcutaneous tissue, bone marrow, inducing panniculitis, polyarthritis and osteonecrosis. Even if caused by an acute pancreatitis abdominal symptoms are often mild or absent in most cases leading to misdiagnosis and poor prognosis.

CONCLUSION

While symptomatic treatment with NSAR and cortisone showed poor to moderate response, causal treatment can be successful depending on the underlying pancreatic disease.

Pancreatic disease, panniculitis, polyarthrtitis syndrome successfully treated with total pancreatectomy: Case report and literature review

INTRODUCTION

Pancreatic disease can be complicated by extrabdominal manifestations such as panniculitis and polyarthritis. The symptomatic triad comprising pancreatic disease, panniculitis and polyarthritis is also known as PPP syndrome and is characterized by severe chronic sequels and high mortality rate. We describe a case of PPP syndrome successfully treated with spleen preserving total pancreatectomy; in addition we performed a literature review.

PRESENTATION OF CASE

A 67 years old male presented panniculitis and polyarthritis without clinical abdominal symptoms. Clinical presentation, laboratory values and radiological findings demonstrated an acute pancreatitis and a pancreatic cancer was suspected; failure of conservatory treatments and high suspicious of malignancy led to perform a spleen preserving total pancreatectomy. Finally histological examination excluded a pancreatic cancer and confirmed a chronic pancreatitis. Patient was discharged with complete resolution of the extrabdominal disease.

DISCUSSION

In literature only 64 cases of PPP syndrome have been reported. Abdominal symptoms do not often appear at presentation and diagnosis may be delayed. Panniculitis develope in any part of the body but especially on the distal parts of the lower extremities, around the ankles and pretibial regions of the legs. Between osteo-articular manifestations polyarthritis is the most common one, although oligoarthritis, and monoarthritis in have been reported.

CONCLUSION

PPP syndrome is a rare disease with a high mortality rate. A timely diagnosis and an aggressive treatment may improve the prognosis of this condition.

Osteomyelitis: A rare complication of pancreatitis and PPP-syndrome

Pancreatic diseases can be accompanied by periarthritis with bone necrosis and panniculitis (PPP-syndrome). It is postulated that this is caused by systemic activity of pancreatic enzymes leading to microcirculatory disturbances and fat necrosis. The morbidity and mortality of the PPP-syndrome is high. Successful treatment of pancreatitis can lead to resolution of accompanying panniculitis and periarthritis without adverse sequelae, but weeks or months after pancreatitis, asymptomatic necrosis of the bone may become symptomatic by fracturing spontaneously. In this report, we also describe osteomyelitis as a severe septic complication of bone necrosis caused by pancreatitis, in one case as acute tissue necrosis and in another case months after pancreatitis spread haematogenously.